The Effectiveness of Virtual Reality Technology for Perioperative Anxiety Among Adults Undergoing Elective Surgery

Abstract

BACKGROUND Perioperative anxiety is a common phenomenon that can have a significant impact on a patient's experience and surgical outcomes. Anxiety can manifest in physical symptoms such as increased heart rate, blood pressure, respiratory rate, sweating, and nausea, as well as psychological symptoms such as fear, worry, and panic. Perioperative anxiety can be caused by a variety of factors, including fear of the unknown, fear of pain, fear of the procedure itself, fear of the outcome, and fear of the environment. In addition, perioperative anxiety can lead to postoperative complications such as pain, surgical site infections, and longer hospitalisation. Pharmacological and non-pharmacological interventions have been used to manage anxiety. Pharmacological interventions include medications such as fentanyl, midazolam, morphine, and ketamine. However, side effects can occur from these medicines, such as breathing difficulties, drowsiness, and interactions with other anaesthesia medications. As a result, non-pharmacological interventions, including music, educational videos, psychological counselling, and social support, are becoming more popular. Recently, there has been an increased interest in using virtual reality (VR) to manage perioperative anxiety. The VR technology provides the user with an immersive experience in a three-dimensional simulated environment by allowing them to interact with the virtual environment. This technology is a major area of interest within the field of perioperative anxiety. To date, most studies in the field have focused on the effectiveness of VR on perioperative anxiety among the paediatric population, with limited research on its effectiveness among the adult population. AIMS To evaluate the effectiveness of VR on perioperative anxiety in the adult population undergoing elective surgery. METHODS A systematic review and meta-analysis of the effectiveness of VR in reducing perioperative anxiety for elective adult surgical patients was conducted (Objective 1). Search strategies were employed to identify the literature without language or date restrictions. Searches were completed by July 2023. Two independent reviewers, with a third where consensus was needed, used standardised critical appraisal instruments from the Joanna Briggs Institute, narrative analysis, and meta-analysis using RStudio software. A prospective observational study among 308 adult patients scheduled for elective surgery was conducted to investigate the prevalence of preoperative anxiety at a major metropolitan hospital in Australia from November 2021 to July 2022 (Objective 2). A self- administered questionnaire was used to measure anxiety levels, and other variables, including age, sex, and type of surgery, were collected from the patient's records. Data analysis included univariate logistic regression to evaluate the significance of independent variables , including age, gender, and surgical type. A two-group, parallel, single-centre, superiority, randomised controlled trial (RCT) of the effectiveness of VR in perioperative anxiety for adult elective surgical patients was conducted (Objective 3) based upon a published protocol. The study was conducted from November 2021 to July 2022 in 95 patients who experienced moderate to high levels of preoperative anxiety. Computer-generated randomisation was used to allocate participants to either the control group or the intervention group, who received 10 minutes of a VR session for relaxation purposes. The primary outcome was perioperative anxiety measured using the Visual Analogue Scale for Anxiety (VAS-A). Secondary outcomes included stress levels as measured by saliva cortisol level and heart rate, postoperative pain, patient satisfaction with perioperative care, hospital length of stay, and VR-associated adverse events. Data was analysed using R and RStudio software. RESULTS A systematic review identified that there was support for the effectiveness of VR in alleviating anxiety and enhancing patient satisfaction. Additionally, a meta-analysis of four studies revealed a small, non-significant reduction in preoperative anxiety based on subjective measurements, favouring VR (SMD -0.29, 95% CI -0.83 to 0.24), with moderate heterogeneity (I2 = 47%). The results of a prospective observational study identified that almost one-third (32.4%, n=100/308) of adult elective surgical patients had significant preoperative anxiety, identified as an Amsterdam Preoperative Anxiety and Information Scale (APAIS) score 11 or higher. Women were three times more likely to experience anxiety than men (OR=3.39, 95% CI 1.97-5.82).Older patients were less likely to experience anxiety, with a reduction in anxiety of 2% for each year above 18 years (OR=0.98, 95% CI 0.97-0.99). In addition, patients were more anxious about the surgery than the anaesthesia, with mean scores of 5.04 (± 2.48) and 3.65 (± 2.07) out of 10, respectively. Over half of the patients (54.9%) reported needing more information about the anaesthesia and surgery. The results of the RCT showed a statistically significant difference in preoperative anxiety levels between the intervention and control groups after the intervention (MD -17% points, 95% CI -23.0 to -11.7). However, there was no statistically significant difference in postoperative anxiety levels between the two groups (MD -7.2% points, 95% CI -17.9 to 3.5). Drowsiness and tired eyes were reported as VR side effects. CONCLUSION Perioperative anxiety among adult surgical patients is often overlooked. Findings suggest that adult surgical patients should be screened for preoperative anxiety, taking into account gender differences, and provide appropriate interventions for those with significant anxiety levels. VR interventions could be considered as a potential treatment option due to their efficacy in the adult population.